Provider Demographics
NPI:1790925105
Name:PHYSICIAN SERVICES OF NORTHEAST CONNECTICUT, LLC
Entity Type:Organization
Organization Name:PHYSICIAN SERVICES OF NORTHEAST CONNECTICUT, LLC
Other - Org Name:WOODSTOCK MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DROUIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-928-6541
Mailing Address - Street 1:320 POMFRET ST
Mailing Address - Street 2:SUITE CSB#2
Mailing Address - City:PUTNAM
Mailing Address - State:CT
Mailing Address - Zip Code:06260-1836
Mailing Address - Country:US
Mailing Address - Phone:860-928-6541
Mailing Address - Fax:860-963-6450
Practice Address - Street 1:168 ROUTE 171
Practice Address - Street 2:
Practice Address - City:SOUTH WOODSTOCK
Practice Address - State:CT
Practice Address - Zip Code:06267
Practice Address - Country:US
Practice Address - Phone:860-928-9270
Practice Address - Fax:860-928-1397
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DAY KIMBALL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-02-25
Last Update Date:2009-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD100000012Medicare PIN